Failure to Administer Medications as Ordered and Inadequate Documentation
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders for one resident, resulting in missed doses of three prescribed medications. The resident, who had a history of a displaced intertrochanteric fracture of the right femur and hypertension, was admitted with orders for Amlodipine for hypertension, Famotidine for GERD, and Linzess for irritable bowel syndrome. On the date in question, documentation showed that the 9 a.m. doses of Amlodipine and Linzess were not administered due to the medications being unavailable, and the 6 a.m. dose of Famotidine was not given because the resident was sleeping. Interviews with nursing staff revealed that the standard procedure when a medication is unavailable is to check the emergency kit (e-kit) and, if not found, notify the physician and document the actions taken in the resident's progress notes. However, review of the resident's electronic medical record showed no documentation that the physician or pharmacy was notified about the missed doses, nor was there any record of follow-up actions or communication regarding the unavailability of the medications. The nurse supervisor confirmed that the facility's policy was not followed in this instance. The pharmacy consultant confirmed that the facility had a new medication dispensing machine and that medications should be accessed from this machine first, with the e-kit as a backup. Despite these resources, the medications were not administered as ordered, and required notifications and documentation were not completed. Facility policy required medications to be administered in a timely manner and within one hour of the prescribed time, which was not adhered to in this case.